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134 Musculoskeletal & Neurological Rehabilitation KCE reports 57 7.2.2 Results Europe pathway is UK, West Yorkshire, Keighley, Airedale General Hospital. The year of publication was not traced. The website of the American Association of Physical Medicine and Rehabilitation (www.aapmr.org) was consulted and 7 articles in the period 2000-2006 were found. We excluded 2 articles by abstract and read 5 articles in full text. We only kept 1 clinical pathway as relevant. The Pubmed database was searched with the keywords critical pathways, integrated care pathway, amputation, amputees and rehabilitation. (See Appendix to chapter 7) The Cinahl database was searched using the keywords amputation care, critical path, amputation stumps, below knee amputation and above knee amputation. (See Appendix to chapter 7) International experts were contacted on this topic (See Appendix to chapter 7). Two reactions were received which seemed useful. It concerned only one real clinical pathway. The other one concerned a theoretical protocol. One clinical pathway was received via the CZV (Centrum voor Ziekenhuis- en Verplegingswetenschap, Leuven). The origin is the Shangi General Hospital, Shangai . All these search algorithms were double checked by a second reader to avoid a selection bias. Four existing critical pathways concerning rehabilitation of patients who had an amputation of the lower extremity, above or below the knee, were selected. Origin Country Number of pathways United Kingdom 1 Belgium 1 America USA 1 Asia Shangai 1 7.2.2.1 Patient characteristics All these pathways concerned planned amputations on a vascular basis, and therefore can not be used for traumatic amputees. 7.2.2.2 Delay after LEA All pathways start in the pre-operative phase, when the decision for amputation is made. For this phase, there are almost no differences between the different pathways. The day of the intervention is only in one path considered as part of the post-acute phase. One pathway indicates that rehabilitation therapy starts at the day after surgery, in two other pathways on day two after surgery. In the other pathway no concrete timing is given. The maintenance phase after therapy starts in the week following surgery (2 pathways), depending on the progression (criteria are discussed in detail in the Appendix) (1 pathway), or is not explicitly described (1 pathway). 7.2.2.3 Method of identification of patient needs Patients’ needs are determined by a multidisciplinary team and comprise medical assessment, level of amputation and premorbid lifestyle, performed. The medical assessment includes a physical examination and evaluation of the mental state. No further detail on the eventual use of standardised assessment instruments is given.
KCE reports 57 Musculoskeletal & Neurological Rehabilitation 135 An assessment is performed in the pre-operative phase. In the other phases no assessments are mentioned. 7.2.2.4 Conditions to start rehabilitation The start of the pre-operative phase is related to the planning of an amputation of the lower extremity. The start of the post-operative phase depends on the patient’s physical evolution, wound healing, stump-modelling, three points march, motivation and cooperation, as mentioned in one pathway. The follow-up factors during all phases of rehabilitation are pain control and a good physical status (criteria not described in detail). 7.2.2.5 Duration of rehabilitation In one pathway the post-operative phase is continued until the day of discharge, 4 weeks after surgery. The pathway stops at the day of discharge. In one pathway, the different phases are based on the patients’ progression (criteria for patient progression are described in the Appendix). The pathway is divided in a preprosthetic training, a prosthetic training and the community integration. A long term follow-up is foreseen until 18 months after surgery. The other pathways contain no exact numbers of days or weeks of each phase following surgery. 7.2.2.6 Involved professionals All rehabilitation programs are organised by a multidisciplinary team. This team includes: • Physicians: orthopaedic (all pathways) and vascular surgeons (all pathways), physical therapist (all pathways) and anaesthesiologist (only 1 pathway in the pre-operative phase); • Nurses (all pathways); one pathway refers to the involvement of a nurse specialised in diabetes mellitus; • Physical therapist and occupational therapist (all pathways); • Recreational therapist (one pathway); • Social worker (three pathways); • Dietician (two pathways); • Podiatrist (one pathway). No distinction between the different phases is made related to team composition. In one pathway the supply of a physio-amputee school is foreseen. 7.2.2.7 Intensity of therapy All rehabilitation programmes foresee physical therapy once a day during inpatient rehabilitation. Concerning outpatient rehabilitation no intensity of therapy is discussed. 7.2.2.8 Type of therapy During the pre-operative phase, all pathways include informing patients and their relatives, in an inpatient setting. The care on the day of intervention is focused on monitoring the physical status of the patient and wound healing.
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